And now, for something completely different...

Or maybe just a little different today.

I want to take you back in time to the 8th or 9th grade. You go to bed having forgotten to study for a test the next day. Morning arrives, you ride your skateboard to school and then it hits you: a TEST! Instead of admitting the error of your ways and rededicating your academic intentions, you hope and pray to anyone who will listen for the teacher to be absent…or a fire drill…or an earthquake…anything! Please let the test not be on this day!!!!!

The Waterman Challenge was that sort of race for me. Sure, it’s only 15 miles and sure, the conditions were calm and overcast. But I didn’t “study” for this race at all. Apparently changing the diapers of a 9 week-old is not the quality cross-training that I had hoped it to be.

My lack of fitness showed up around 8 miles into the race in the form of dead and exhausted arms. My prayers for a water spout…or a hurricane…or a shark lasted for the next 7 miles. I needed something, no...anything...that would give me an excuse to turn to shore. Just like in the 8th grade, my wishes went unanswered and I had to finish my “test”.

With 2009 being the 14th running of the event, the Waterman Challenge is an open water paddleboard race from Swamis beach in Encinitas to Windansea beach. The event is open to traditional (prone) paddleboards and stand up paddleboards with separate divisions for differing lengths of boards.

This year’s overall winners were Rob Rojas on a SUP in 2:06:33 and George Plsek on an unlimited in 2:09:14. My under-prepared body floated across the finish line a half an hour later like a dead whale carcass carried by the currents.

The lessons to be learned from this race? Firstly: if you want to do well on your “test”, you have to “study” for it regularly and often. I know I could have spent less time over the past month watching the French Open, the Penn Relays, etc. and more time swimming and on my board. And secondly: there’s never a shark around when you need one.

SUP is 'sup

What do golfers and stand up paddlers have in common? Not very much. And no, I’m not trying to make a joke at the expense of SUP-ers. The answer is: elbow pain.

I have been seeing an explosion in the number of medial elbow pain cases over the past few months. All of these patients are stand up paddlers and nearly every one of them is new to the sport. There are a lot of areas I would expect to be the “weakest link” in a SUP-er. What surprises me is that, as of yet, the ONLY SUP-related injury I am treating is medial epicondylitis, or “golfer’s elbow”.

There is some debate about the etiology of golfer’s elbow: is it the repeated and high velocity concentric contraction of the forearm flexor group during the mid phase of the swing or the ever so slight but real eccentric contraction of the forearm flexors as the club head strikes the ball? I’ll let the researchers sort that one out. I have tough enough a time getting the ball to go through the windmill, under the mushroom and come out of the waterfall to land next to the hole! :P

With SUP, the flexion motion of the forearm muscles (the extrinsic flexor muscles of the hand/wrist plus the pronator teres and quadratus) is much more powerful than in golf, but much slower as well. This probably removes the eccentric model. This is important because eccentric-type contraction injuries (in my experience) are much more acute and cause significantly more inflammation (think soccer player rupturing a hamstring as her knee extends beneath her) when compared to concentric-type injuries (think cyclist NOT stretching his hamstrings over thousands of miles of training). This puts the typical SUP-er in an overuse category of muscle injury (cumulative trauma disorder) rather than a one-time traumatic injury.

So what, you ask? I went through the hundreds of hours of post-graduate courses to learn Active Release Technique®, which is intended to treat exactly this type of injury. While ART® works fantastically well, the best course of action is to avoid the injury in the first place.

Well, how do you avoid CTD problems? Deal with them before they become a problem (duh!!). If you’re a SUP-er and you are asymptomatic (no pain, no numbness, no weakness) start stretching the forearm ASAP. Even though we’re discussing a flexor problem, I would recommend stretching the wrist and elbow extensors, as well. As for strength exercises, the act of paddling gives the flexors enough of a workout already. So focus on strengthening the wrist extensors, supinator and elbow extensors (triceps and anconeus).

There’s no guarantee that you won’t become injured, but at least no one will mistake you for a golfer.

Happy Father's Day!

In honor of Father’s Day (and my first one as a Dad) is a quick look back at a study from about 6 years ago.

In a STUDY at the University of Wisconsin, researchers showed that dark beer significantly reduced markers for platelet aggregation, which can lead to clotting that causes heart attacks in patients with atherosclerosis. The Wisconsin researchers compared the effects of light and dark beers on dogs with narrowed arteries, similar to those in humans with heart disease.

Measurements of platelet markers for various cellular processes involved in platelet aggregation were taken before and after the administration of the light and dark beers. Afterwards the dogs were given epinephrine, a stress/fight-or-flight hormone previously shown to reverse the anti-clotting effects of drugs like aspirin. Only the dogs administered dark beer were protected against the reversal of its antithrombotic effect.

Researchers theorize that certain polyphenolic compounds are responsible for the cardio-protective effect of beer. As such, they continue to seek that key ingredient that protected the dogs from clotting. I believe we have already found the key ingredient……it’s called Guinness stout! "Administer" one or two today at the barbeque!

Another Way to View Piriformis Problems

I work with a LOT of runners. I am very accustomed to the typical tight hamstring and/or tight external hip rotators (piriformis, superior gemellus, obturator internus, inferior gemellus, quadratus femoris and gluteus maximus). When I work on any of those muscles, I often follow the anatomy train (for a FANTASTIC anatomy read, check out Anatomy Trains by Myers) across the pelvis to the opposite side quadratus lumborum (QL).

This month’s moment of epiphany occurred thanks to working on a few dozen athletes at a regional USA Track and Field meet two weeks ago. So many of the athletes exhibited the typical tight external hip rotators and tight opposite side QL that I began to wonder: “How many hip patients have I seen over the years who had this same combination of hip and opposite side low back issues?”

Each one of those runners at the meet was shocked when, after performing ART on the symptomatic hip, I would then work on an equally tender QL on the opposing side. They would ask “Why does that hurt, too?” They were even more surprised to find that they could not hold a side bridge plank with that QL for more than a few moments.

My theory is that upward pull of the tight QL changes the orientation of the opposite femur relative to the pelvis. This altered positioning in turn leads to a tighter external rotator of the hip. The tightness eventually leads to pain that diminishes with therapy, but returns with activities.

Fast forward to today. While hanging out at a local bike shop between patient appointments, I watched a Retul road bike fitting taking place. With every stroke of the pedal, the customer’s left knee swung outward at the top of the pedal stroke. When the cyclist would rest in between computer measurements, I observed his right iliac crest (hip) approximately 1” higher than the left regardless of his position on the bike. And finally, the Retul system “detected” his LEFT leg as longer than his RIGHT leg---meaning my observation of a higher right iliac crest correct. Unfortunately, the “Retul” solution to this problem is to shim the “short” leg. The system isn’t intelligent enough to recognize the interconnectivity of muscle groups and anatomical regions.

Even though there is a supposed relationship between the glute medius and the opposite side QL (see Trendelenberg exam), I constantly find that hip external rotator problems travel with the opposite side QL. What this means is if you have a piriformis problem that never completely goes away, add a routine of QL stretching---especially on the opposite side.

The other take-home message is be careful when someone offers shims or orthotics to account for a “short” leg. If the leg actually is shorter, then an orthotic device is a great and necessary approach. But too much of the time there is a tight group of muscles pulling the pelvis and causing the “short” leg. Find a knowledgeable health care provider to give a thorough evaluation of the entire body before sticking devices beneath your feet.

Listen to your patients!

Here’s a lesson for patients and health care providers. I recently evaluated a patient who was suffering from carpal tunnel syndrome. He had lived with pain and numbness in one hand that began a little over a year ago.

These symptoms were treated with cortisone injections, which temporarily relieved the symptoms. After a few rounds of cortisone, he finally relented and underwent a carpal ligament release. And: problem solved. No more pain in that hand.

Then a few months ago he felt the same symptoms of pain and numbness in the OTHER hand. Not wanting to go through injections and surgery, he sought more conservative care first. Twelve visits to a physical therapist did not help. Six more visits to a chiropractor who is an Active Release Technique provider also did not help.

So in front of me sat a man who was running out of patience and hope. Carpal tunnel syndrome does tend to be a “mechanical” problem---something occupies the space of the tunnel and presses on the median nerve. If you remove or reduce that occupying “mass”, the symptoms go away. Very often, the “mass” is somewhere else along the path of the median nerve (pronator teres, antecubital fossa, medial intermuscular septum, etc.).

What was odd was the success, albeit temporary, of the cortisone injection coupled with the absolute failure of the other approaches (which included ART, stretching, strength training, ultrasound, electrical stimulation and ice).

Chiropractors are not experts in pharmacology. That stated, most chiropractors (and physical therapists) become very familiar with the 40 or 50 most commonly prescribed medications. This patient was taking a heart medication that was NOT familiar to me. A quick search through the PDR (Physician’s Desk Reference) followed by a phone call to my favorite pharmacist (thanks for taking my call so quickly, Dave) confirmed my suspicions.

This patient seemed to be suffering from a side-effect of a medication he was taking. When I asked the patient if he had spoken to this cardiologist (who prescribed the drug) about his carpal tunnel syndrome symptoms, he said “no”. He did not think a heart doctor would know or care about hand problems. Similarly, his general practitioner was unaware of his heart medication (same logic employed here, too). And finally, on his initial patient paper work, he failed to include this drug as something he currently takes. I had to ask him in order to learn about it. I made him phone his cardiologist from my office to set up an appointment for later that day.

When I spoke to the patient recently, his cardiologist had altered the medication about a month earlier. His pain and numbness were completely gone. I wish I could say it is because I treated him so well—all I did was talk to and examine him!

The lesson—patients: tell your health care provider EVERYTHING. Let him/her decide if it is germane to your condition. And doctors: if you’re not helping within the first 2 weeks, you’re not going to help. At that point, change your course of treatment or find someone with a different perspective.

How to and how NOT to breathe

I was at a local 5K/10K last weekend watching a few hundred finishers on the course. When I watch runners I can't help but to pick apart their gait issues (or, in some cases, their blessed gait). For whatever reason, what I saw was a LOT of breathing issues.

I don't mean asthma or COPD, but people who--despite running at or near their top speed--were not moving their abdomen at all. As an example of how to do it right, think about video you've seen of Lance Armstrong during any of his Tour de France wins. As he climbs up some awful grade, his belly moves in and out so much with each breath that he appears.....overweight. But during those races I doubt his body fat percentage is greater than 5%. He is doing an amazing job of letting the primary muscles of respiration (diaphragm, internal and external costals) do the job of inspiration. Granted, he is a professional athlete and genetically blessed, etc.

I made similar observations during the finish of the 5k/10k. The top 10% of runners came through with their chests relaxed, shoulders (upper traps) down and relaxed and their stomachs moving nicely in and out with each breath. A strong majority of the remaining 90%, however, looked like their shoulders were glued to their ears.

Diaphragmatic breathing (aka belly breathing) is a breathing technique historically practiced by yogis and more recently in the treatment of symptoms of asthma and COPD.

In the past, I haven't considered counseling athletes and weekend warriors on diaphragmatic breathing. And the fastest among us don't seem to need the advice. In fact, the patients to whom I usually recommend diaphragmatic breathing have been patients with neck complaints. During times of stress, whether physical or emotional, we seem to "turn on" the accessory muscles of inspiration---upper trapezius, sternocleidomastoids, scalenes, serratus posterior superior, et al. A lesson in belly breathing could help all of us.

No matter what your "sport" is---running, engineering, weights, accounting, paddling, typing, golf, parenting, cycling, etc---practice the techniques of diaphragmatic breathing and relaxation. Unless, of course, you WANT to become a "neck patient".